BLS Basic Life Support Patient Care Standards. Emergency Health Services Branch Ministry of Health and Long-Term Care

BLS Basic Life Support Patient Care Standards Emergency Health Services Branch Ministry of Health and Long-Term Care

BLS Basic Life Support Patient Care Standards January 2007 Version 2.0 Emergency Health Services Branch Ministry of Health and Long-Term Care

To all users of this publication: The information contained herein has been carefully compiled and is believed to be accurate at date of publication. Freedom from error, however, cannot be guaranteed. Enquiries regarding the purchase and distribution of this manual should be directed to: Publications Ontario By telephone: 1-800-668-9938 or 416-326-5300 By fax: 613-566-2234 TTY: 1-800-268-7095 Online: www.publications.gov.on.ca For further information on the Basic Life Support Patient Care Standards, please contact: ISBN 1-4249-2122-8 (Print) ISBN 1-4249-2123-6 (PDF) ISBN 1-4249-2124-4 (CD-ROM) Queen s Printer for Ontario, 2006 Emergency Health Services Branch Ministry of Health and Long-Term Care 5700 Yonge Street, 6th Floor Toronto, ON M2M 4K5 Phone 416-327-7900 Fax 416-327-7911

Acknowledgements This revision of the Basic Life Support Patient Care Standards is the result of the assistance of a number of groups and individuals, such as Paramedics, EMS Directors, Base Hospital staff, Base Hospital Medical Directors, College Coordinators, Field Offices, Ornge (formerly Ontario Air Ambulance Services Co.), Legal Services Branch and Regional Training Coordinators. In particular, the Ministry would like to gratefully acknowledge the following individuals for their significant contributions: Dr. Rick Verbeek on behalf the Ontario Base Hospital Group Medical Advisory Committee Ms. Lynne Urszenyi i

Tips on using the interactive Basic Life Support Standards Ctrl + F = Find forward and back arrows Esc. key Alt + left arrow Use this to search the enitre document for all instances of a specific word or phrase. allows you flip pages (you can also use the arrow keys on your keyboard) escape out of full screen mode. returns to previous view (i.e. return to Table of Contents)

Table of Contents Preface...1 Definitions...2 Purpose of Basic Life Support Patient Care Standards...2 Purpose of Basic Life Support Patient Care Guidelines...2 Objectives of Implementation of the Standards...2 Practice and the Basic Life Support Patient Care Standards...3 Review and Revision of the Basic Life Support Patient Care Standards...3 Abbreviations Standard...5 Section 1 General Standard of Care A. Personal and Patient Safety and Protection...1-2 B. Patient Communication...1-4 C. Patient Assessment - General Principles...1-4 D. Patient Assessment - Environmental Assessments...1-4 E. Patient Assessment - Historical Assessments...1-5 F. Patient Assessment - Physical Assessments...1-5 G. Patient Management...1-8 H. Patient Transport... 1-12 I. Patient Refusal of Treatment and/or Transport... 1-13 J. Patient Care Enroute to the Receiving Facility... 1-15 K. Radio Reporting of Patient Care to Receiving Facility... 1-16 L. Radio Patch to Base Hospital or Other Attending Physician... 1-16 M. Transfer of Responsibility for Patient Care... 1-17 N. Documentation of Patient Care... 1-18 Patient Care Skills... 1-19 Air Ambulance Utilization Standard... 1-23 DNR Standard... 1-30 Policy 4.6 Inter-Facility Do Not Resuscitate Orders... 1-31 Intravenous Line Maintenance Standard...1-41 Load and Go Patients Standard...1-45 Oxygen Therapy Standard...1-48 Paramedic Conduct Standard... 1-51 Patients with Vital Signs Absent (Transportation) Standard... 1-54 Physician s Orders Standard... 1-58 Police Notification Standard... 1-59 Self-Administered Medications Standard for EMAs/Paramedics...1-62 Table of Contents iii

Section 2 Medical Patient Categories Introduction...2-1 Key Code for Short Forms and Abbreviations...2-1 Medical Patient Assessment (Overview)...2-2 Medical Format, Short Form of General Standard of Care...2-4 Abdominal Pain, Non-traumatic...2-7 Airway Obstruction General Standard...2-9 Alcohol Ingestion/Withdrawal...2-12 Allergic Reaction Known or Suspect... 2-14 Back Pain No History of Trauma... 2-16 Cardiac Arrest Adults... 2-18 Cardiac Arrest Children...2-20 Cerebrovascular Accident (CVA, Stroke ) Conscious Patient No Known History of Trauma... 2-21 Chest Pain Non-traumatic...2-23 Coma (Unconscious) Markedly Decreased Level of Consciousness Cause Unknown, No Known History of Trauma...2-25 Diabetic Problem...2-27 Epistaxis Non-traumatic...2-29 Extremity Pain No Known History of Trauma... 2-31 Fever... 2-33 Gastrointestinal (GI) Bleeding, Vomiting, Coughing Blood; Passing Blood Rectally... 2-35 Headache No History of Trauma... 2-37 Overdose, Poisoning, Drug Ingestion Known or Suspect... 2-39 Respiratory Arrest Adults...2-41 Respiratory Arrest Children...2-42 Seizure Adult/Child...2-43 Shortness of Breath, Breathing Difficulty in Adults and Children Not Related to Trauma...2-46 Swallowing Difficulty or Pain Dysphagia...2-50 Syncope (Faint) No History of Preceding Trauma...2-52 Testicular Pain Non-traumatic or History of Minor Trauma, Strain...2-54 Vaginal Bleeding (Non-Pregnant Patient, Pregnancy Unknown)... 2-55 Vision Problem Non-traumatic, No History of Foreign Body...2-56 Section 3 Trauma Patient Categories Introduction...3-1 Key Code for Trauma Mnemonics and Short Forms...3-2 Trauma Patient Assessment (Overview)...3-3 Trauma Format Short Form of General Standard of Care...3-5 Abdominal/Pelvic Injury Blunt, Penetrating... 3-11 Amputation, Avulsion Complete/Partial...3-13 Chest Injury Blunt, Penetrating...3-15 Extremity Injury Bone/Joint... 3-18 iv Table of Contents

Eye Injury Blunt, Penetrating...3-21 Facial and Nose Injury Blunt, Penetrating...3-23 Foreign Bodies Eye/Ear/Nose...3-26 Foreign Body Inhaled/Swallowed (Known/Suspect) Conscious Patient...3-27 Genital Injury in the Male Isolated Injuries...3-29 Head Injury Blunt, Penetrating...3-30 Neck/Back Injury Blunt, Penetrating...3-33 Sexual Assault (Suspect)...3-38 Soft Tissue Injuries (Wounds) General Assessment and Management Standard... 3-40 Section 4 Environment-Related Disorders Bites Animal/Human...4-2 Burns Thermal... 4-4 Chemical Injury Eye/Skin...4-7 Cold Injury Frostbite, Hypothermia... 4-11 Drowning and Near-Drowning... 4-14 Electrocution/Electrical Injury... 4-17 Hazardous Materials Exposure Assessment and Management Guidelines...4-19 Heat-Related Illness...4-24 Inhalation Injury Smoke, Steam, Fumes, Other Noxious Gases...4-26 Scuba Diving Injuries/Disorders...4-27 Snake Bites...4-29 Section 5 Obstetrical Conditions Pregnant Patient General Assessment and Management Standard...5-1 Breech Delivery... 5-4 Emergency Delivery... 5-6 Labour... 5-10 Limb Presentation... 5-14 Mechanism of Normal Delivery...5-15 Midwives at the Scene Standard... 5-16 Multiple Births... 5-18 Neonatal Assessment and Management...5-19 Premature Labour and Delivery (Onset of labour at <35 completed weeks of gestation)...5-22 Premature Rupture of Membranes/Prolapsed Umbilical Cord...5-23 Seizure in the Pregnant Patient...5-25 Trauma in the Pregnant Patient...5-27 Traumatic Maternal Cardiac Arrest...5-29 Vaginal Bleeding Known Pregnancy, No History of Trauma...5-30 Table of Contents v

Section 6 Pediatrics Section 7 Geriatrics Pediatric General Assessment and Management Standard...6-1 Pediatric General Assessment and Management Additional Guidelines...6-3 Child Abuse (Suspect)...6-7 Sudden Infant Death Syndrome...6-9 Geriatric Assessment and Management Standard...7-1 Elder Abuse (Suspect)...7-5 Physiological Changes of Aging... 7-7 Section 8 Psychiatric Disorders The Psychiatric Patient General Assessment and Management Standard...8-1 Emotionally Disturbed Patients Care and Transportation Standard...8-3 Restraint of Patients Standard... 8-6 The Violent, Aggressive or Agitated Patient...8-9 vi Table of Contents

Preface The BLS Patient Care Standards state the Ministry of Health and Long-Term Care expectations with respect to how paramedics will interact with their patients. The standards set out a logical ordering of the inter-related activities and practices of paramedics, activities which start with the patient s entry point to, and end with, their exit point from the ambulance system. Process standards are intended to be instructive and educative, and should facilitate service delivery. They are intended to maximally protect patients from receiving inappropriate care, and service providers from being subjected to inappropriate legal suits, disciplinary actions, etc. In creating the standards, an assessment-based approach was utilized e.g. a standard was developed for assessment and management of shortness of breath, rather than for asthma. In the field setting, providers MUST focus on the following three aspects of patient care: a) identifying serious disruptions to critical functions - airway, breathing, circulation and level of consciousness; b) applying measures to correct these disruptions as soon as feasible, and, c) determining the need for, and where required, initiating rapid transport. Attempting to make a definitive diagnosis in the field may lead to unnecessary delays in treatment and transport. Diagnosis is of secondary importance in field practice. Each standard has been designed: a) to ensure that patient care is appropriate, safe, timely and efficient; b) to allow paramedics to exercise judgement as required by the situation; c) to account for the many diverse and adverse scene conditions which may, in some instances, alter the care provided to patients suffering from the same or similar illnesses or injuries. Where a standard was not deemed feasible or practical, guidelines have been incorporated with certain standards. The guidelines are intended to direct paramedics towards desired practices for unusual and/or less commonly encountered field situations. The benefits of having standards are obvious. All paramedics can now be assessed using the same objective criteria. Preface 1

Definitions For purposes of this manual the following definitions apply: Paramedic Standards Guidelines Paramedic is the same as defined under the Ambulance Act and for the purposes of this standard includes Emergency Medical Attendant as defined under the Ambulance Act and Regulation 257/00 or as may be amended from time to time, unless otherwise indicated. Criteria which will define the minimum acceptable levels or range of Basic Life Support patient care performance for ALL paramedics in Ontario. General statements intended to provide information and guidance with respect to formulation of working assessments, or, directing principles of preferred practice applicable to specific clinical circumstances where a standard is not reasonable or appropriate. Purpose of Basic Life Support Patient Care Standards To state the minimum acceptable level or range of Basic Life Support patient care performance expected of paramedics in all Ontario ambulance services, while recognizing circumstances in the field which may result in or require deviation from the minimum standards. Purpose of Basic Life Support Patient Care Guidelines To direct, guide and assist paramedics performance of Basic Life Support level patient care. Objectives of Implementation of the Standards 1. To ensure that Basic Life Support level patient care is performed in a safe, efficient, appropriate and timely manner. 2. To provide a measure of protection for patients receiving service and individuals providing service. 3. To provide a rational basis for paramedics decision-making and judgements. 4. To assist less experienced paramedics or recent graduates in developing and focusing decision-making skills, and to assist more experienced paramedics in refining and perfecting these skills. 5. To provide a fair and objective basis for assessment of paramedics performance. 2 Preface

6. To identify training and continuing education needs of paramedics. 7. To provide direction in the development of assessment and testing programs for paramedics. 8. To provide direction in the development of audit and other quality assurance objectives for ambulance service operators, medical control authorities and others involved in quality assurance activities for ambulance services. 9. To provide assistance and direction in decision-making for Emergency Health Services Branch staff, ambulance service operators, and others involved with resource allocation. Practice and the Basic Life Support Patient Care Standards 1. A paramedic may practice at a level or levels above the standards specified in this manual if: a) They are qualified to do so, and, b) Such practice is in accordance with their ambulance service policies. 2. When issuing directives to paramedics on patient care related topics, ambulance service operators must ensure that such directives are compatible with the standards. 3. If a paramedic performs patient care activities which they have not been trained or approved to perform, or the standard of care is not met, they may be subject to investigation and/or other actions as dictated by Ministry standards, policy, legislation and the circumstances and events surrounding the incident. Review and Revision of the Basic Life Support Patient Care Standards The standards will be reviewed at regular intervals to be determined by the Ministry of Health and Long-Term Care (MOHLTC) and by means of a Ministry approved process. Revisions will be made as necessary to ensure that the standards remain current. Preface 3

4

Abbreviations Standard A B C abdomen...abd/abdo acute myocardial infarction...ami administer/administration...admin. Advanced Emergency Medical Care Assistant...AEMCA Advanced Life Support...ALS after meals...pc air entry...a/e, A/E airway, breathing, circulation...abcs airway, breathing, circulation, deficits (neurologic)...abcds alpha...α ambulance call report...acr ambulance communications service...acs ambulatory...amb. American Pediatric Gross Assessment Record...APGAR amount...amt. ante-partum hemorrhage...aph anterior...ant. approximately...approx. or as required, as necessary...prn at...@ at bedtime...hs automated external defibrillator...aed bag valve mask...bvm base hospital physician...bhp basic life support...bls before meals...ac beta...β bilateral...bilat. /bil. birth control pill...bcp blood...bld. blood pressure...bp booked...bkd. bowel movement...bm bowel sounds...bs by mouth...po caesarean section...c-section /C. sect. cancer...ca /CA capsule(s)...caps Abbreviations 5

carbon dioxide...co 2 carbon monoxide...co cardiopulmonary resuscitation...cpr cardiovascular system...cvs catheter, catheterization...cath. celcius (degree)...c centimetre...cm central ambulance communication centre...cacc central nervous system...cns cerebrospinal fluid...csf cerebrovascular accident...cva cervical spine...c-spine chief complaint...cc chronic obstructive pulmonary disease...copd circulation...circ n complains of/complaining of...c/o computerized axial tomography...cat computerized tomography...ct congestive heart failure...chf coronary artery disease...cad coronary care unit...ccu Canadian Triage and Acquity Scale...CTAS D daily...od date of birth...dob dead on arrival...doa decompression sickness...dcs decreased... deep vein thrombosis...dvt deep breathing and cough...db & C defibrillation...defib. delirium tremens...dts dextrose 5% in water...d 5 W dextrose 50% in water...d 50 W dextrose 3.3% & 0.3% sodium chloride...⅔, ⅓ diagnosis...dx diarrhea & vomiting...d&v digitalis, digoxin...dig. dilatation/dilation and curettage...d&c discharged...dc discontinue...d/c do not resuscitate...dnr dorsalis pedis (pulse)...dp dressing...drsg. drop(s)...gtt(s) 6 Abbreviations

E F G H ears, nose and throat...ent electrocardiogram...ecg, EKG emergency department, room, unit...ed, ER, EU emergency medical attendant...ema emergency medical care assistant...emca emergency medical service...ems endotracheal tube...ett equal...= estimated time of arrival...eta ethanol, ethyl alcohol...etoh every...q expected date of confinement (due date)...edc expiration...exp. eye(s), ear(s), nose, throat...eent family history...fh feet (measure)...ft. or female... first degree...1 foreign body...fb four times a day...qid fracture...fx. or # gastrointestinal (tract)...gi or GIT genitourinary (tract)...gu or GUT Glasgow Coma Score...GCS gram...g greater than...> greater than or equal to... gynecology...gyn head and neck...h & N head injury...hi heart rate...hr Heart & Stroke Foundation of Ontario...HSFO height...ht hemoglobin...hgb /HB highway...hwy history...hx history of present illness...hpi hour...hr Abbreviations 7

I J K L M immediately...stat inches...in / increased... inferior...inf. injury, injection...inj. inspiration...insp. intensive care unit...icu intracranial pressure...icp intramuscular...im intravenous...iv intermittent positive pressure ventilation...ippv irregular...irreg. ischemic heart disease...ihd jugular venous distension...jvd keep vein open...kvo kilogram...kg kilometres...km laceration...lac large...lg. last/last normal menstrual period...lmp/lnmp leads to, implies... left...l or Lt. left lower lobe (lung)...lll left lower quadrant (abdomen)...llq left upper lobe (lung)...lul left upper quadrant (abdomen)...luq less than...< less than or equal to... level of awareness...loa litre...l loss of consciousness, level of consciousness...loc lumbar spine...l-spine male... markedly decreased... markedly increased... mechanism of injury...m. of I. medications...med(s) mercury...hg middle...mid 8 Abbreviations

milligram...mg millilitre...ml millimetre...mm minute...min. moderate...mod. motor vehicle accident...mva motor vehicle collision...mvc multiple casualty incident...mci myocardial infarction...mi N O P nasogastric (tube)...ng /NGT nausea, vomiting...n & V nausea, vomiting, diarrhea...n, V, D negative...- /neg. /-ive neurology/neurologic...neuro nitroglycerin...nitro no, none...ø no change...n/c no known allergies...nka normal...n normal saline...ns or N/S not applicable, not asked, not assessed...na, NASK, NASS nothing by mouth...npo not yet diagnosed...nyd number...# obstetrics...obs on arrival...o/a on examination...o/e once a day...od operating room...or oriented to person, place and time...oriented x1: x2: x3 orthopedics...ortho out-patient, out-patient department...op, OPD overdose...od oxygen...o 2 palpation...palp. paroxysmal atrial tachycardia...pat patient...pt. pediatrics...peds. per rectum...pr personal protective equipment...ppe per vagina...pv pick up (location)...p/u Abbreviations 9

plus/minus...+/- police constable number...pc # positive...+/pos./+ive possible...poss. posterior...post. post-operative...post-op post partum hemorrhage...pph potassium...k +, K prior to arrival...pta problem...prob. pupils equal and reactive to light...pearl, PERL R S range of motion...rom red blood cells...rbcs regarding...re regular...reg. respirations...resp. respiratory rate...rr respiratory therapist...rt return of spontaneous circulation...rosc right...r, Rt. right lower lobe (lung)...rll right lower quadrant (abdomen)...rlq right middle lobe...rml right upper quadrant (abdomen)...ruq Ringer s lactate...rl rule out...r/o sacral spine...s-spine second...sec second degree...2 semi-automated external defibrillator...saed shortness of breath...sob shortness of breath on exertion...soboe small...sm, sml sodium chloride (salt)...nacl solution...sol n spontaneous abortion...sa strong and irregular...str/irreg or S/I strong and regular...str/reg or S/R subcutaneous...sc or SQ sublingual...sl or S/L Sudden Infant Death Syndrome...SIDS superior...sup. supraventricular tachycardia...svt 10 Abbreviations

T U v tablet(s)...tab(s) temperature...temp. temperature, pulse, respirations...tpr therapeutic abortion, time of arrival...ta therapy, prescription, treatment...r x third degree...3 thoracic spine...t-spine three times a day...tid times...x to keep open...tko to keep vein open...tkvo transient ischemic attack...tia tuberculosis...tb twice a day...bid unequal... unit...u upper respiratory tract infection...uri, URTI urinary tract infection...uti vaginal...vag vital signs...vs vital signs absent...vsa volume...vol. w water...h 2 O weight...wt white blood cells...wbcs with...c / w within normal limits...wnl without...s / w/o y year...yr years old...y/o, y/o Abbreviations 11

12

General Standard of Care Section 1 General Standard of Care

Conditions The General Standard of Care is applicable: 1. At all times when a paramedic is providing patient care while on duty. 2. To patient care provided by a paramedic where care is general in nature (stated or implied). 3. To patient care pertaining to certain illness or injury categories/situations as specifically defined within the General Standard of Care. 4. Under all environmental conditions, with the proviso that personal safety is assured or can be secured without loss of the paramedic s life, limb(s) or vital functions. Givens 1. Patient(s). 2. A partner (exceptions - see Note to follow). 3. An operational ambulance (includes air ambulances), or in special situations such as mass casualty incidents, an emergency first response vehicle. 4. Fully operational patient care equipment as per the MOHLTC Provincial Equipment Standards for Ontario Ambulance Services. Note: If a paramedic is on-scene alone in a first response situation, the only Given may be the patient. Under these circumstances, the paramedic will be expected to perform to the best of their abilities and will attempt to meet the standards within the restrictions imposed by the situation. Section 1 General Standard of Care 1-1

A. Personal and Patient Safety and Protection Pre-Arrival At Scene, At Scene The Paramedic will: 1. On receipt of a call, confirm call information with dispatch. Ensure that patient location and access information is accurate. 2. Use an appropriate route and speed to respond to the scene. Adhere to approved driving and occupant restraint policies and practices. Operate the ambulance and utilize ambulance emergency warning devices in a responsible manner. Use an appropriate alternate route if the route selected is impeded due to traffic, weather, etc. 3. On arrival at scene, perform an assessment of the environment. Park the ambulance in a safe place, as close to the point of patient contact as possible. Identify obvious and potential hazards to the patient(s) and crew. Where appropriate, identify routes of entry and exit, e.g. for multiple patient incidents; for potential violence or confrontation. 4. Secure the environment if assessment indicates there is no danger to self or others. 5. If danger exists, or there is uncertainty regarding personal and/or patient safety, request assistance from allied emergency services personnel/agencies. Initiate and/or maintain communication with ambulance dispatch. 6. Use call and scene information to determine the type of equipment and supplies likely to be required to manage problem(s). Unless prohibited by adverse conditions at scene, carry all essential patient care equipment and supplies to the site of initial patient contact. 7. Determine if there is more than one patient and assess the need for additional resources and assistance. If indicated, initiate triage as per Multiple Casualty Incident (MCI) principles. 8. Use EMS rescue and extrication techniques as required. 9. Utilize personal protective equipment according to the Ambulance Service Patient Care and Transportation Standard and take appropriate safety measures where necessary. 10. Work with your partner to ensure safe, efficient and timely patient assessment and care. If there is confusion at scene and/or bystanders are interfering with or obstructing patient assessment/management, request police assistance. In the interim, attempt to control the scene while your partner conducts patient assessment or have your partner control the scene. Alternately, instruct another responsible adult to secure the scene. 11. Advise the patient to remain still when deemed necessary e.g. for patient safety, to reduce injury potential and/or to carry out appropriate patient assessments and management. 12. Protect the patient from hazards and exposure to adverse environmental conditions. 1-2 Section 1 General Standard of Care

13. Ensure safe disposal of sharps in an appropriate sharps container. 14. Secure, lift and carry the patient using appropriate methods and devices. 15. Wash hands after each patient contact. If multiple patients or other circumstances at scene prevent hand-washing after each patient contact, use appropriate alcohol-based hand sanitizer or, at minimum, change gloves between patient contacts and wash hands as soon as circumstances permit. General Measures 1. Ensure that other operational procedures which impact directly or indirectly on patient care, are carried out on a regular basis. Specifically: Personal cleanliness, dress, conduct, safety and work performance; Cleanliness, decontamination, safety, maintenance and routine checks of the ambulance, ambulance premises, and all patient care related equipment and supplies; Completion and submission of Ambulance Call Reports (ACRs), incident reports and other operational documents; Familiarization with and working in accordance with legislation, standards and pertinent policies and procedures, specifically those dealing with occupational health and safety and communicable diseases; Participation in training and continuing education activities; Assistance with familiarization and orientation of new or less experienced staff. 2. In cases of unusual or suspicious situations, (e.g. suspected foul play, suicides) follow, in addition to the general and specific standards, the procedures outlined in the Police Notification Standard. Section 1 General Standard of Care 1-3

B. Patient Communication The Paramedic will: 1. Identify and introduce themselves to the patient and/or to bystanders at scene. Advise the patient that they are there to help. If the patient refuses treatment, see Section I of the General Standard of Care. 2. Attempt to determine the patient s name, gender, age (or approximate), and weight (or approximate). 3. Treat the patient and others at scene with respect and courtesy. Exercise tact and diplomacy. 4. Explain assessments and interventions. 5. Provide verbal, and where deemed appropriate, tactile comfort and reassurance to the patient and family/friends, including the unconscious patient. Assume that the unconscious patient is capable of both hearing and understanding. C. Patient Assessment - General Principles The Paramedic will: 1. On all scene calls, regardless of dispatch priority coding, assume the existence of serious, potentially life-, limb- and/or function-threatening conditions until assessment indicates otherwise. 2. If a physician is at scene, follow specific procedures as outlined in the Physician s Orders Standard, in addition to those outlined in the General Standard of Care. D. Patient Assessment - Environmental Assessments The Paramedic will, concurrent with or following other assessments: 1. Make scene observations. 2. Seek medical information tags/jewelry, medications, and other forms of patient identification. 3. Collect and transport all patient medications and other relevant identification for review by receiving facility staff. Document reasons if relevant identification is left at scene, e.g. suspect foul play, obvious crime scene; police prevent removal. 1-4 Section 1 General Standard of Care

E. Patient Assessment - Historical Assessments The Paramedic will, concurrent with or following the primary survey: 1. Establish the chief complaint: why did the patient or bystander call for an ambulance? 2. Elicit history of present illness or incident. Utilize as many appropriate methods as required, specifically: Question the patient directly; question others at scene. Seek medical or other identification, e.g. medical information tags/jewelry, medication containers. Observe the patient s behaviour. Request/collect information on allergies, medications and relevant past medical history unless prohibited by time and/or the severity of the patient s condition or adverse scene circumstances. Make scene observations. 3. For inter-facility patient transfers, obtain the following information and/or transfer documents: pertinent patient history and care information; verbal and/or written treatment orders from the sending physician; transfer papers, e.g. case summary, lab work, x-rays, list of personal effects accompanying the patient, etc.; name(s) of hospital staff and equipment accompanying the patient, where applicable; name of receiving facility and receiving physician, where applicable. F. Patient Assessment - Physical Assessments The Paramedic will: 1. Handle the patient gently. Minimize patient movement and manipulation. 2. Immediately on patient contact, perform the primary survey: Quickly note the patient s general appearance, degree of distress. Ensure manual C-spine protection if trauma is obvious, suspect or unknown. Assess airway patency, breathing, circulation and level of consciousness and identify critical findings; look for and if possible, quickly expose obvious or suspect external hemorrhage and injury sites; use the AVPU mnemonic to assess the level of consciousness - Alert, responds to Voice, responds to Pain; Unresponsive. Upon identification of absent/inadequate airway, breathing or circulation (ABCs) immediately perform appropriate interventions to establish, improve and/or maintain the ABCs and to control external wound hemorrhage (see Section G - Patient Management). Section 1 General Standard of Care 1-5

3. Complete the primary survey within 2 minutes unless major problems are encountered, e.g. persistent airway obstruction, cardiac arrest. 4. Determine the need for rapid transport ( load and go ) after completion of the primary survey, i.e. obvious/impending instability of the patient s respiratory, cardiovascular and/or neurologic status, or the potential for instability is high, based on assessment. 5. Initiate rapid transport for all patients who meet load and go criteria as specified in the Load and Go Patients Standard. Perform further assessment and management enroute. 6. If a patient is determined to be stable after the primary survey, perform further assessments at scene, or transport patient and perform enroute. 7. Initiate cardiac monitoring for the following types of calls: VSAs (exception - obvious death as discussed in Patients with Vital Signs Absent (Transportation) Standard); respiratory arrest; severe respiratory distress; unconscious/decreased level of consciousness; collapse; syncope; chest pain; shortness of breath; CVA; post-ictal patients; overdose (unless known to be a non-toxic ingestion); major or multiple trauma; electrocution; near-drowning/scuba diving incidents; hypothermia; heat exhaustion/heat illness; abnormal vital signs e.g. RR <8-10/minute or >28-30/minute; BP <90; HR >l20 or <60/minute, or alterations in rhythm patterns; if requested by sending staff (for inter-facility transfers). 8. Unless contraindicated (see specific standards), cover the patient with a blanket after the primary survey, or at the latest, after the secondary survey. Blanket before or during the primary survey if indicated, e.g. severe shock; environmental conditions exacerbating heat loss; the need for privacy. 9. Expose body parts only as required to perform appropriate assessments and management. Attempt to maintain the patient s comfort and privacy. If exposure (and assessment) is limited due to the patient s condition, document specific reasons for omissions when completing the Ambulance Call Report e.g. need to keep patient movement to a minimum, prevent heat loss, institute cooling, control shock, etc., or, ensure that routine documentation clearly reflects the situation at scene. 1-6 Section 1 General Standard of Care